Provider First Line Business Practice Location Address:
1441 SE 122ND AVE
Provider Second Line Business Practice Location Address:
SUITE G
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97233-1270
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-255-2191
Provider Business Practice Location Address Fax Number:
503-255-1609
Provider Enumeration Date:
01/11/2007